Print version ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.101 n.10 Cape Town Oct. 2011

In the English-speaking world and some parts of Europe, problem and pathological gambling are treated as a significant public health problem. At the same time, these jurisdictions recognise that for most of those who engage in it, gambling is a harmless leisure activity that may yield public benefits by contributing more in taxation than other leisure industries and/or contributing to out-of-town tourism.1,2 Strategies that combine minimising the harm caused with maximising the benefits of gambling are therefore crucial for good public policy. Such lessons may also be relevant to other legal and illegal industries, such as those involving the production and sales of alcohol, where analogous harms and benefits exist.

Gambling in South Africa was originally treated as immoral and largely prohibited, apart from horse-racing. Subsequently, casinos were allowed to develop, most famously the Sun City resort, in what the South African government then regarded as self-governing 'homelands'. With the arrival of a democratic dispensation and the incorporation of the homelands into the provinces, national legislation required the legal position of these casinos to be regularised. More importantly, new legislation was required to address the huge increase in illegal machine gambling throughout South Africa in the late 1980s. On the basis of a report by a government commission established before 1994, the new government passed a National Gambling Act in 1996 that permitted a national maximum of 40 casinos to be licensed and regulated by provincial governments, with each province being allocated its own maximum number. The Act also provided for the introduction of a national lottery and the eventual legalisation and regulation of limited payout machines (LPMs, with a maximum jackpot of R500) in venues such as bars. Having recognised that it was right and in its interests to do so, the South African gambling industry established a National Responsible Gambling Programme (NRGP) which began operating in 1999. It was subsequently agreed that this programme should be overseen by regulators as well as by industry executives through a not-forprofit, Section 21 company chaired by someone independent of both public and private sector interests. South Africa has therefore not only pioneered responsible gambling in the developing world, it has also established a unique organisational structure for ensuring that industry executives and regulators collaborate on this issue, each bringing their special expertise to the solution of problems. This work may therefore be of interest to local clinicians and others in South Africa and abroad.

The NRGP and its work

The NRGP has three main divisions that work closely together within a common structure: treatment, prevention and research.

Treatment begins with the provision of a free counselling line through which problem gamblers and those close to them can get expert, confidential help 24/7. Counsellors are specially trained in gambling problems. They then refer clients who want this to a treatment network, comprising some 75 treatment professionals distributed in 53 towns and cities in southern Africa. The NRGP funds and trains these practitioners to provide evidence-based therapy, including an initial evaluation. Clients with complex gambling problems can obtain free psychiatric consultation and access to a debt-counselling service, including other mental health and addiction issues. Family members may also receive counselling if they wish to.

From its inception to February 2011, the NRGP's toll free counselling line (0800 006 008) received more than 308 000 calls; 12 810 callers were referred for free treatment (or about 100 per month on average), and 107 received inpatient treatment for pathological gambling.

Prevention consists mainly of educating actual and potential problem gamblers about the dangers of gambling and how to avoid them. This takes the form of problem gambling awareness campaigns targeted both at the population at large and at vulnerable communities including the young, the poor and those receiving benefits. These are conducted by print, television and radio advertising, distributing promotional and informational leaflets, brochures and newsletters, and participation in community outreach initiatives and special events. A key aspect of public education informs the public that individual treatment is available around the clock and free of charge. Research conducted by Ipsos Markinor in 2010 showed that some 75% of South African adults living in Gauteng knew that gambling can become as serious a problem as drink and drugs. About the same percentage of casino patrons also knew that free help is available to problem gamblers and their families, and they had heard of the work of the NRGP. For patrons of shopping malls these figures fell to 25%, which is still encouraging. The NRGP has also developed a specific programme for school-goers, which addresses not only gambling but also decision-making in general, and which teachers have rated as highly effective.3 The NRGP also provides ongoing education to gambling boards, the gambling industry, the medical community, and a range of other sectors.

A particularly innovative prevention work currently being developed and delivered by the NRGP is its programme called 'Taking Risks Wisely', which deals with all risk-taking behaviours - not just gambling - and provides a text-based teachers' manual with lesson plans, interactive exercises, etc. plus full web-based back-up including a comprehensive Handbook of Responsible Gambling. This has been piloted as part of the life skills curriculum for Grades 7 - 9, and material for Grades 10 - 12 will be completed next year.

NRGP research

The Research Division has included academics at local universities and collaborators abroad. The research objective has been to understand the nature, causes and prevalence of problem gambling, to facilitate the development of good public policy, and to enhance the effectiveness of prevention and treatment strategies. The NRGP conducted four prevalence studies between 2001 and 2009, available on the website (www.responsiblegambling.co.za). It has also conducted followup research on selected participants and others, and research into gambling and poverty and the neurophysiology of problem gambling. A book4 and several scholarly publications in print or under review have resulted from NRGP-commissioned research.

Among the main research findings have been that the prevalence of problem gambling, although somewhat higher overall in South Africa, has remained more or less stable or has slightly declined since 2000; that the rural poor hardly gamble at all, but excessive gambling at informal and illegal venues is a problem in South African townships; that the lottery produces more problems for players than in more affluent jurisdictions; and that gambling problems are significantly correlated with other psychological disorders such as substance abuse, depression and anxiety.

Conclusion

After more than 10 years in operation, the NRGP is widely regarded by those who have studied or evaluated it, within South Africa5 and from abroad,6 as being effective in minimising the harm caused by excessive or uncontrolled gambling. The gambling industry in South Africa is perceived as being well regulated and as trying to deliver mostly harmless entertainment in a socially responsible way. It is also widely acknowledged to be exceptionally cost-effective.

The Programme receives stable funding from the industry in South Africa at 0.1% of winnings from players, but the governance and operation of the NRGP occurs independently of both legislators and industry representatives. All expenditure is fully audited and reported upon in quarterly and annual reports, which are publicly available.

The main problems facing the NRGP are how to ensure that more of those who would benefit from treatment actually seek it; how to get our messages across to people gambling informally in the townships; and how to address the problem of psychiatric co-morbidities.